Purpose: To evaluate an alternative retinopathy of prematurity (ROP) screening system that identifies infants meriting examination by an ophthalmologist in a middleincome country. Methods: The authors hypothesized that grading posterior pole images for the presence of pre-plus or plus disease has high sensitivity to identify infants with type 1 ROP that requires treatment. Part 1 of the study evaluated the feasibility of having a non-ophthalmologist health care worker obtain retinal images of prematurely born infants using a non-contact retinal camera (Pictor; Volk Optical, Inc., Mentor, OH) that were of sufficient quality to grade for pre-plus or plus disease. Part 2 investigated the accuracy of grading these images to identify infants with type 1 ROP. The authors prospectively recruited infants at Chulalongkorn University Hospital (Bangkok, Thailand). On days infants underwent routine ROP screening, a trained health care worker imaged their retinas with Pictor. Two ROP experts graded these serial images from a remote location for image gradability and posterior pole disease. Results: Fifty-six infants were included. Overall, 69.4% of infant imaging sessions were gradable. Among gradable images, the sensitivity of both graders for identifying an infant with type 1 ROP by grading for the presence of pre-plus or plus disease was 1.0 (95% confidence interval [CI]: 0.31 to 1.0) for grader 1 and 1.0 (95% CI: 0.40 to 1.0) for grader 2. The specificity was 0.93 (95% CI: 0.76 to 0.99) for grader 1 and 0.74 (95% CI: 0.53 to 0.88) for grader 2. Conclusions: It was feasible for a trained non-ophthalmologist health care worker to obtain retinal images of infants using the Pictor that were of sufficient quality to identify infants with type 1 ROP.

Purpose: To evaluate (1) the feasibility of nonophthalmologist healthcare workers (HCWs) obtaining images of sufficient quality for retinopathy of prematurity (ROP) screening using a Food and Drug Administration-approved portable, noncontact, narrow-field fundus camera (i.e., Pictor; Volk Optical, Inc, Mentor, OH) and (2) the accuracy of grading these images to identify infants in whom treatment-warranted (type 1) ROP developed. Design: Prospective cohort study. Participants: Infants undergoing routine ROP screening examinations (i.e., birth weight ≤1500 g, gestational age ≤30 weeks, or both, or selected infants with a birth weight of 1500–2000 g or gestational age >30 weeks and an unstable clinical course). Methods: We prospectively recruited infants undergoing ROP screening examinations at a community hospital. On the same day an ophthalmologist examined them, a trained HCW imaged their retinas using the noncontact camera. Two masked ROP experts graded these images remotely. We calculated both the percentage of gradable images (i.e., having at least 3 quadrants with sufficient image quality), as well as the accuracy of identifying infants in whom type 1 ROP developed. Main Outcome Measures: Percentage of gradable images and the sensitivity and specificity of each grader for identifying infants with type 1 ROP by grading for the presence of preplus or plus disease. Results: Ninety-nine infants were included. Overall, 92.4% and 94.2% of all infant imaging sessions were considered gradable by graders 1 and 2, respectively. Among gradable images, the sensitivity of both graders for identifying type 1 ROP by grading for the presence of preplus or plus disease was 100% (95% confidence interval [CI], 95%–100%), and the specificity was 91% (95% CI, 83%–95%) for grader 1 and 93% (95% CI, 86%–96%) for grader 2. Conclusions: It was highly feasible for trained HCWs to obtain digital retinal images of sufficient quality for ROP screening using a noncontact fundus camera. By grading for the presence of preplus or plus disease, graders identified infants in whom type 1 ROP developed with high sensitivity and specificity. The use of portable, noncontact retinal cameras by trained HCWs could increase our workforce in ROP screening and identify infants needing indirect ophthalmoscopy examinations by an ophthalmologist.

Waldenström macroglobulinemia (WM)/lymphoplasmacytic lymphoma (LPL) is a rare, chronic B-cell lymphoma with high heritability. We conduct a two-stage genome-wide association study of WM/LPL in 530 unrelated cases and 4362 controls of European ancestry and identify two high-risk loci associated with WM/LPL at 6p25.3 (rs116446171, near EXOC2 and IRF4; OR = 21.14, 95% CI: 14.40–31.03, P = 1.36 × 10−54) and 14q32.13 (rs117410836, near TCL1; OR = 4.90, 95% CI: 3.45–6.96, P = 8.75 × 10−19). Both risk alleles are observed at a low frequency among controls (~2–3%) and occur in excess in affected cases within families. In silico data suggest that rs116446171 may have functional importance, and in functional studies, we demonstrate increased reporter transcription and proliferation in cells transduced with the 6p25.3 risk allele. Although further studies are needed to fully elucidate underlying biological mechanisms, together these loci explain 4% of the familial risk and provide insights into genetic susceptibility to this malignancy.

PURPOSE: To compare the results of visual acuity testing in a population of deaf children using the Handy Eye Chart versus the Lea Symbols Chart and to compare testability and preference between charts. METHODS: A total of 24 participants were recruited at the Atlanta Area School for the Deaf. Visual Acuity was evaluated using the Handy Eye Chart and the Lea Symbols Chart. Patient preference and duration of testing were measured. RESULTS: The mean difference between the visual acuity as measured by each chart was -0.02 logMAR (95% CI, -0.06 to 0.03). Testing with the Handy Eye Chart was an average of 13.79 seconds faster than testing with the Lea Symbols Chart (95% CI, 1.1-26.47; P = 0.03). Of the 24 participants, 17 (71%) preferred the Handy Eye Chart (95% CI: 49%-87%; P = 0.07). CONCLUSIONS: The Handy Eye Chart is a fast, valid, and useful tool for measuring visual acuity in deaf children age 7-18 years. Additional research is needed to evaluate the utility of the Handy Eye Chart in younger children and deaf adults.

Objective: To investigate the outcomes of strabismus surgery in patients with a prior history of a scleral buckling procedure for retinal reattachment. Methods: We reviewed the medical records of 18 patients who underwent strabismus surgery following a scleral buckling procedure and investigated the effect of multiple variables on postoperative alignment after strabismus surgery including gender, age, surgeon, number of strabismus surgeries, adjustable suture use, previous pars plana vitrectomy, preoperative best-corrected visual acuity, and scleral buckle removal. Outcomes were considered successful if there was ≤10 prism diopters (PD) residual horizontal and/or ≤4 PD residual vertical deviations. Statistical analyses were performed using Fisher's exact test, Mann-Whitney test, and nominal logistic regression. Results: Success using our criteria of motor alignment was achieved in 6 of 18 eyes (33%). A higher rate of success was found in the scleral buckle removal group (success with buckle removal, 62.5%; success without buckle removal, 10.0%; p = 0.04). Nominal logistic regression analysis showed scleral buckle removal was the most significant factor associated with successful surgical alignment (p = 0.03; odds ratio = 16.67). Although the success rate was higher in the adjustable suture group (50% in adjustable group vs 14.3% in non-adjustable group: Fisher's exact test, p = 0.30), this difference was not statistically significant. No retinal redetachments occurred after scleral buckle removal. Conclusions: These results suggest that scleral buckles can be safely removed in selected patients with strabismus following retinal reattachment surgery and scleral buckle removal may improve ocular alignment following strabismus surgery.

Objective: To assess whether outcomes of strabismus surgery are improved by using the adjustable suture technique and to determine which subgroups of strabismus patients benefit most from the adjustable suture technique. Design: A retrospective chart review. Participants: Five hundred thirty-five adults who had strabismus surgery between 1989–2010. Methods: Success was defined as ≤10 prism diopters (PD) for horizontal deviations and ≤2 PD for vertical deviations. Differences in the proportion of successful strabismus surgery were analyzed using a chi-square test with an alpha of 0.05. Main outcome measures: Ocular alignment in primary position at a 7-day to 12-week follow-up examination. Results: 491 patients met the inclusion criteria (adjustable suture, n=305; non-adjustable, n=186). The success rates for non-adjustable and adjustable groups were 61.3% and 74.8% respectively (χ2=9.91, p=0.0016). Adjustable suture use was particularly beneficial for patients undergoing a reoperation for childhood strabismus (success rate: non-adjustable, 42.4%; adjustable, 65.7% p=0.0268; n=100). The differences in outcomes were not statistically significant for patients with childhood strabismus undergoing a primary surgery (non-adjustable, 65.0%; adjustable, 81.4% p=0.1354; n=90) or with thyroid orbitopathy (non-adjustable, 76.7%; adjustable, 74.1% p=0.8204; n=57). Conclusions: Strabismus surgery using adjustable sutures was associated with improved short-term ocular alignment compared to strabismus surgery without the use of adjustable sutures. Adjustable sutures were most beneficial for patients undergoing reoperations for childhood strabismus.

Purpose: To determine whether measurements obtained by partial coherence interferometry (PCI) correlate well with measurements obtained using immersion ultrasound (US) in children. Setting: Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA. Design: Evaluation of a diagnostic test or technology. Methods: The charts of pediatric patients who had cataract surgery from August 2008 to September 2009 were reviewed. Axial length (AL) measurements in the operative eye were obtained using PCI at the preoperative clinic visit and then using immersion US in the operating room before surgery. The data were compared to determine the degree of agreement. Results: The charts of 18 patients (27 eyes) were reviewed. Preoperative AL measurements by PCI were obtained in 21 eyes (78%). On average, the PCI-measured ALs were 0.1 mm less than the immersion US values (95% confidence interval, −0.2 to −0.1; P = .002). All eyes with an AL of 23.5 mm or less had lower PCI values than immersion US values. There was no systematic pattern of 1 measurement being greater or less than the other in eyes with an AL longer than 23.5 mm. Conclusions: There is a systematic difference in AL measurement between PCI and immersion US, with PCI tending to give lower values, particularly in eyes with an AL longer than 23.5 mm. Depending on the length of the eye, a 0.1 mm error in AL measurement could result in a 0.25 to 0.75 diopter difference in intraocular lens calculation that could be clinically significant in some patients.

IMPORTANCE: Intravitreous bevacizumab (0.25 to 0.625 mg) is increasingly used to treat type 1 retinopathy of prematurity (ROP), but there remain concerns about systemic toxicity. A much lower dose may be effective while reducing systemic risk. OBJECTIVE: To find a dose of intravitreous bevacizumab that was lower than previously used for severe ROP, was effective in this study, and could be tested in future larger studies. DESIGN, SETTING, AND PARTICIPANTS: Between May 2015 and September 2016, 61 premature infants with type 1 ROP in 1 or both eyes were enrolled in a masked, multicenter, phase 1 dose de-escalation study. One eye of 10 to 14 infants received 0.25 mg of intravitreous bevacizumab. If successful, the dose was reduced for the next group of infants (to 0.125 mg, then 0.063 mg, and finally 0.031 mg). Diluted bevacizumab was delivered using 300 μL syringes with 5/16-inch, 30-gauge fixed needles. INTERVENTIONS: Bevacizumab injections at 0.25 mg, 0.125 mg, 0.063 mg, and 0.031 mg. MAIN OUTCOMES AND MEASURES: Success was defined as improvement in preinjection plus disease or zone I stage 3 ROP by 5 days after injection or sooner, and no recurrence of type 1 ROP or severe neovascularization requiring additional treatment within 4 weeks. RESULTS: Fifty-eight of 61 enrolled infants had 4-week outcomes completed; mean birth weight was 709 g and mean gestational age was 24.9 weeks. Success was achievedin 11 of 11 eyes at 0.25 mg, 14 of 14 eyes at 0.125 mg, 21 of 24 eyes at 0.063 mg, and 9 of 9 eyes at 0.031 mg. CONCLUSIONS AND RELEVANCE: A dose of bevacizumab aslow as 0.031 mgwas effectivein 9 of 9 eyes in this phase 1 study and warrants further investigation. Identifying a lower effective dose of bevacizumab may reduce the risk for neurodevelopmental disability or detrimental effects on other organs.

Background: Horizontal strabismus due to a weak rectus muscle can be treated with an augmented Hummelsheim procedure, in which both vertical rectus muscle tendons are split, resected by 4 mm, and reattached to the sclera adjacent to the weak rectus muscle. Compared with vertical rectus transposition, the procedure spares two ciliary vessels and does not require placement of augmentation sutures. In this study, we evaluated binocular alignment and ocular motility in patients with abducens nerve palsy treated with an augmented Hummelsheim procedure. Methods: The medical records of consecutive patients with complete abducens nerve palsy who underwent the augmented Hummelsheim procedure, usually combined with medial rectus muscle recession, were retrospectively reviewed. Binocular alignment, ocular motility, and complications were analyzed. Results: Ten patients (age range, 12-57 years) met inclusion criteria for the study, of whom 9 of 10 had simultaneous medial rectus recession. Follow-up ranged from 1 week to 24 months. The augmented Hummelsheim procedure improved esotropia from 43Δ ± 5 Δ preoperatively to 6Δ ± 7 Δ postoperatively (P < 0.0001) and reduced abduction deficits from -4 to -3 (P < 0.0001). One patient with coexisting oculomotor nerve palsy developed consecutive exotropia; 2 had induced vertical deviations. There were no cases of anterior segment ischemia. Conclusions: The augmented Hummelsheim procedure combined with medial rectus muscle recession reduced mean primary position esotropia and improved abduction in patients with complete abducens nerve palsy.

Background/aims To report the long term outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia associated with purely refractive accommodative esotropia. Methods Retrospective chart review of 40 patients age 17–39 who underwent PRK to eliminate their dependence on glasses. Pre and post-operative best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive spherical equivalent (SEQ), ocular alignment, and stereoacuity were reviewed. Results Forty patients (80 eyes) with mean age 27.9 years were treated for a mean pre-operative SEQ of +3.06D hyperopia. The mean final post-operative SEQ was +0.06. Pre-operative BSCVA was 0.04 logMAR, and did not change post-operatively. Mean UCVA significantly improved from 0.30 logMAR preoperatively to 0.08 logMAR post-operatively. Mean pre-operative esotropia at distance and near was 18.6 PD. All patients were orthophoric without correction at the one month, one year, and final post-operative evaluations. Visual acuity, refractive error and alignment remained stable after the one year post-operative examination. Stereoacuity was unchanged in 80% of patients postoperatively. There were no complications. Conclusion PRK can be used to treat low to moderate hyperopia associated with purely refractive accommodative esotropia in young adults.